Over the last twenty years, the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and the prescription of stimulant medications for ADHD have increased significantly in the United States. While prescription stimulants are efficacious when used appropriately, there is growing concern regarding the nonmedical use of prescription stimulants (NUPS) by adolescents and young adults. Because the primary source of stimulants used nonmedically by adolescents is other adolescents, we face significant challenges in reducing NUPS while at the same time providing necessary stimulant therapy to adolescents with ADHD.
In order to better understand school-level and individual factors associated with NUPS, a team of researchers, including Timothy Wilens, MD, Chief of the Division of Child and Adolescent Psychiatry and the Co-Director of the Center for Addiction Medicine, examined secondary school students’ medical and nonmedical use of stimulants.
The study used self-reported data collected between 2005 and 2020 from the Monitoring the Future (MTF) study, a multicohort survey of nationally representative samples of US secondary school students (8th, 10th, and 12th grade) to improve our understanding of school-level prevalence and risk factors for NUPS. The analysis included data from 3284 US secondary schools and a total of 231,141 8th-, 10th-, and 12th-grade students (50.8% female; 11.8% Black, 16.2% Hispanic, 53.1%, White, 19.0% other race and ethnicity).
Across US secondary schools, there was wide variation in the prevalence rates of school-level medical use of prescription stimulants. The percentage of the student body reporting medical use of prescription stimulants ranged from 0% (1266 schools) to over 25% (115 schools). Overall, about 8.0% of the students received treatment with a stimulant during the previous year.
The prevalence of nonmedical use of prescription stimulants also varied considerably, ranging from 0% of the students (1706 schools) to more than 25% of students (58 schools) reporting nonmedical use of stimulants. Overall, about 6.0% of the students reported nonmedical use of a stimulant during the previous year.
What Factors Drive Nonmedical Use of Stimulants?
The likelihood of a student engaging in NUPS during the previous year were higher at secondary schools with higher proportions of students reporting the medical use of stimulants for ADHD. Students attending schools with the highest rates of prescription stimulant therapy for ADHD had an approximately 36% increased odds of past-year NUPS compared to students attending schools with no medical use of prescription stimulants (adjusted odds ratio, 1.36; 95% CI, 1.20-1.55). Other significant school-level risk factors included schools with higher proportions of parents who reported higher levels of education, schools in non-Northeastern regions, schools located in suburban areas, schools with a higher proportion of White students, and schools surveyed in more recent cohorts (2015-2020).
Individual-level factors also played an important role. For example, adolescents who had been treated with a stimulant for ADHD had about a 2.5-fold greater risk of nonmedical stimulant use compared to those who had never used stimulants.
School-Level Factors Must Be Considered in Prevention Efforts
This is the first national study to examine school-level prevalence of and risk factors for the nonmedical use of prescription stimulants (NUPS) among US secondary school students. Past-year NUPS prevalence varied considerably across schools, with 0% to 25% or more of the student body reporting NUPS. The current study identifies school-level stimulant therapy for ADHD as an environmental risk factor for individual- and school-level NUPS, indicating that school-level stimulant therapy for ADHD must be taken into consideration when monitoring NUPS and in developing risk-reduction strategies and prevention efforts. This is especially important given that peers are a leading source for stimulants used nonmedically among adolescents.
Given the significant variability across schools with regard to the prevalence of stimulant therapy for ADHD, the authors recommend that, rather than relying solely on regional, state, or national recommendations, individual schools must assess their own student body to guide their prevention efforts. The school context, including the attitudes and behaviors of fellow students regarding stimulant therapy for ADHD, NUPS, and the use of other substances are important factors influencing the prevalence of NUPS in a given school.
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McCabe SE, Schulenberg JE, Wilens TE, Schepis TS, McCabe VV, Veliz PT. Prescription Stimulant Medical and Nonmedical Use Among US Secondary School Students, 2005 to 2020. JAMA Netw Open. 2023 Apr 3;6(4):e238707.
Schepis TS, Wilens TE, McCabe SE. Prescription Drug Misuse: Sources of Controlled Medications in Adolescents. J Am Acad Child Adolesc Psychiatry. 2019 Jul;58(7):670-680.
